Helping Our Patients to Stop Smoking

May 31, 2007
Mauro Mecca, MD

Internal Medicine World Report, September 2006, Volume 0, Issue 0

Dr Mecca is attending physician, Department of Medicine, Hackensack University Medical Center, Hackensack, NJ, and an internist in private practice, Lodi, NJ.

Just about every time a smoker comes to my office, I advise that patient to quit smoking. Indeed it is not fun to give this advice, only to find yourself in a confrontational position with a perfectly nice patient. After all, the patient is doing something that he or she considers to be one of life’s little pleasures.

At times it must seem to patients that doctors are neopuritans. We tell them, “Don’t smoke, don’t drink, don’t eat the foods you enjoy, practice safe sex, avoid the sun,” and so on. After a while people look at you and begin to wonder.

Still, I make it my professional “business” to counsel my patients, especially the smokers among them. The health implications of smoking are just too serious for physicians to ignore.

Atherosclerosis and myocardial infarction (MI) have been linked to cigarette smoking in many studies. An interesting footnote is that heart attack was not a recognized medical event in ancient times. Hippocrates, Galen, and Maimonides were great clinical observers. In fact, their clinical descriptions of various diseases can still be used in modern medical textbooks, yet they never described a heart attack. This is curious, since an MI is such a dramatic and unforgettable occurrence. As all contemporary doctors know, patients pre-sent with chest pain—often radiating to the arm—sweating, shortness of breath, and an irregular pulse, which can be followed by death. Surely, if the ancients saw a person with these signs and symptoms we now associate with an MI, they would have described it in their writings.

There is documentation that significant numbers of people in ancient times lived to their dotage and ate very high-fat diets, yet no description of heart attacks can be found in those days. In fact, MI is not described until 1908 in the Russian medical literature and 1919 in the American medical literature. What happened then, you may ask?

In 1880, a young Virginian named James Bonsack designed a certain machine. He had put tobacco in one end of it, paper in the other end, turned a crank—and out came a perfectly formed cigarette. With that, the mass production of cigarettes became possible, and within 30 years the world began seeing the massive epidemic of coronary artery disease and heart attack.

We now have good evidence that this epidemic has begun to wane in groups that have quit smoking. Almost every school-aged child in the United States knows that Eli Whitney invented the cotton gin and changed American history. I wonder how many Americans know about that other Southern invention.

Lung cancer is, of course, another convincing reason to quit smoking. Again, lung cancer was relatively rare until the 20th century. It, too, is clearly linked to introduction of cigarette smoking. As a clinician, it is easier for me to counsel an adversarial patient to stop smoking than to tell a patient he or she has this largely incurable disease (ie, lung cancer). It is a touching irony to observe that patients immediately and futilely stop smoking when presented with this diagnosis. It begs the question, why could they not stop smoking before?

Counseling patients to stop smoking is not easy. Often the session can become difficult. Almost all patients know that smoking is harmful, yet they continue to smoke. Physicians need to probe gently at the psychologic defenses or offer other insights and information about smoking cessation.

One of the most common things patients who smoke tell me is that they firmly intend to quit—but not today. Well, when? Soon, they say, within the week, month, year, and so on.

Everybody knows that procrastination is not acceptable, so I tell my patients the following story. “Let’s suppose that you have worked hard and have saved more than $80,000 in cash. Just to be safe, you keep the money in federally insured accounts in a bank run by your best friend. One day you get a call from your friend. He says, ‘This bank is going to fail a week from this Tuesday. For reasons best unsaid, no one will insure your money if it’s still on deposit here when we close at 4:00 pm next Tuesday. It will be gone forever, and no power on earth will restore it. But don’t worry, come anytime between now and then, and your money will be fine.’

Then I ask my patient, “Even though you have more than 5 days to retrieve your money, how long would it take you to get to the bank?” Virtually everyone says “immediately.” Money strikes an immediate cord. But when it comes to stopping smoking and risking their health, patients want to negotiate the date.

After hearing this, most patients smile and realize they really should not delay. I then usually ask them if they have young children. If they do, I ask what their children think about their parent smoking. The answer is almost always the same; the kids don’t like it. In fact, our culture gives license for children to lecture their parents on this subject. The children do, because they are terrified that something bad will happen to their parent.

I try to take this a bit further. When children are young, they will tirelessly lecture their parents on this issue, but when they reach age 15 or 16 they stop lecturing. However, these patients cannot be too surprised if their kids start smoking themselves. After all, who are the children going to mimic? Parents are the greatest and most significant role model for a young person. I tell my patients that it is a terrible legacy if their kids mimic them and smoke themselves. Sometimes this is effective.

Counseling patients is rarely easy, but it is often effective. Studies have shown that when a physician simply tells a patient to stop smoking, this often has a beneficial effect. Since cigarette smoking remains just about the most detrimental legal habit that a patient can have, physicians must always make the effort to discuss this important issue with their patients.

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